Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
A. Administer oxygen to the client.
B. Collect a urine sample.
C. Check the client's vital signs.
D. Stop the infusion.
The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN adult medical surgical 2019 with NGN - Proctored Exam 3. Take the full exam now
Full Explanation
The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.
Similar Questions
A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?
A. The amount of drainage is gradually decreasing.
B. The client's abdomen becomes distended and firm.
Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation. The nurse should report this finding to the provider and assess for signs of shock or peritonitis.
C. The client reports being extremely thirsty with a sore throat.
D. The drainage is bright green in color with brown fecal material.
Full Explanation
Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation.
The nurse should report this finding to the provider and assess for signs of shock or peritonitis.
A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?
A. Confusion
Confusion can be a sign of delirium, which is a common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration. The nurse should assess for other causes of confusion, such as infection or hypoxia, and implement interventions to prevent or treat delirium.
B. Blurred vision
C. Diarrhea
D. Polyuria
Full Explanation
Confusion can be a sign of delirium, which is a common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration. The nurse should assess for other causes of confusion, such as infection or hypoxia, and implement interventions to prevent or treat delirium.
A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take?
A. Allow visitors to hold the client's hand.
B. Leave the door to the client's room open.
C. Place the dosimeter film badge on the client's door.
D. Wear a lead apron when providing client care.
Wear a lead apron when providing client care. Internal radiation therapy (brachytherapy) is a type of treatment that uses a radioactive source placed inside or near the tumor . The nurse should wear a lead apron to protect themselves from exposure to radiation when caring for the client. The other actions are not appropriate for a client receiving internal radiation therapy.
Full Explanation
Wear a lead apron when providing client care. Internal radiation therapy (brachytherapy) is a type of treatment that uses a radioactive source placed inside or near the tumor . The nurse should wear a lead apron to protect themselves from exposure to radiation when caring for the client. The other actions are not appropriate for a client receiving internal radiation therapy.